Surgical errors climb, bed sores decline in Connecticut hospitals

Lisa Chedekel

Published 11:40 pm, Friday, December 28, 2012

Reports of surgeries on wrong body parts are on the rise at Connecticut hospitals, as are patient deaths or disabilities resulting from surgery or falls. But the state's medical institutions are doing a better job at preventing bed sores in patients.

That's according to the Adverse Event Report, released by the state Department of Public Health. The report catalogues the frequency of "adverse medical events" -- a term used to describe a injury or illness that occurs as the result of medical care -- at all the state's hospitals.

The most common incidents were deaths or serious injuries caused by falls, which made up 36 percent of all adverse medical events last year. Despite myriad efforts to reduce falls in hospitals, 96 patients died or were seriously injured from falling in 2011 -- up from 91 the year before. Hospitals with the highest numbers of falls included Charlotte Hungerford and Stamford hospitals, which each had nine cases.

Though less common, surgeries on the wrong body part -- an error that has been policed closely in recent years-- have risen steadily since 2009, when there were two such incidents reported.

In 2010, there were eight reports of wrong-site surgeries and, in 2011, there were 13 incidents.

Although hospitals have adopted checklists and other measures to reduce wrong-site surgeries, those measures alone haven't eradicated human error, said Dr. Mary Reich Cooper, vice president and chief quality officer for the Connecticut Hospital Association.

"There's a lot of focus right now on mindfulness. . . being mindful, instead of just going through the protocol," she said. There is also an increasing emphasis on "a team approach" to preventing surgical errors, so that no one person is responsible for safety checks.

Reports of patient deaths or serious disability as a result of surgery also rose, from 16 incidents in 2010 to 21 last year. Five of the incidents were reported at Middlesex Hospital, but officials there said only one of the cases resulted in a death, while the other four were cases in which patients lost large amounts of blood but were not seriously harmed. Eight other hospitals reported one to three cases.

Perforations during open, laparoscopic and endoscopic procedures that resulted in death or serious disability remained high among hospitals, at 49 -- up slightly from 2010. Bridgeport and Hartford hospitals each had six such cases.

But there was some good news in the report. Reports of patients suffering from bed sores declined last year, dropping from 48 in 2010 to 39. Even better, 18 of the state's 30 acute-care hospitals reported no incidents of pressure ulcers.

Cooper said the state's hospitals are making extensive efforts to identify patients at risk of falls and bed sores upon admission, and to reduce the likelihood of harm.

Despite these steps, pressure sores were the third most common adverse event, making up 14.6 percent of such incidents.

Because errors are self-reported, state officials caution that some of the variation in rates could be due to underreporting. In July, a report by the U.S. Office of Inspector General found that many adverse events were not reported. In a representative sample of Medicare patients' cases, 12 percent of the adverse events detected on chart reviews met state reporting requirements, but only 1 percent were actually reported, the study found.

The Department of Public Health reviews all hospital errors but does not investigate every case. From Jan. 1, 2012, through Nov. 30, the department investigated about 27 percent of reported adverse events, according to department spokesman Bill Gerrish. From 2007 to 2010, about 23 percent of cases were investigated, last year's report shows. In 2011, about 35 percent of the reported adverse events were investigated.

Department officials said not every error warrants an investigation, and the agency targets instances where there is noncompliance with regulations or inadequate standards of care. The decision to investigate also is influenced by how often the type of event has been investigated before, and whether the department is satisfied with a corrective plan that must be submitted by the hospital after an error is reported.

The new report notes that funding for part-time physician consultants to assist with case reviews was cut in 2010, hampering the department's ability to conduct thorough investigations.

In responses included in the report, most hospitals with high error rates described initiatives they were taking to reduce errors.

Stamford Hospital, which urged that adverse-event reporting be viewed "in the context of the complexity of the patients cared for by the organization," highlighted its efforts to reduce patient falls through a more detailed fall-risk assessment and targeted interventions for specialized patient populations.

St. Vincent's touted its safety measures as well, including daily "safety huddles," which encourage staff to speak openly about safety concerns. "Safety huddles also promote accurate detection and reporting of actual and near-miss events," says the hospital's statement. "Timely detection and investigation help us identify where improvements can be made for all patients, as well as determine which reported events are not preventable."